Reimbursement Form - Redwood Health Services

Reimbursement Form - Redwood Health Services

Reimbursement Form
Fax completed form to 707-525-4223 or mail to:
Redwood Health Services • 3510 Unocal Place, Suite 108 • Santa Rosa, CA 95403
Group Name _______________________________________________________ Contact Phone Number ______________________________
Employee Last Name ____________________________________________________ First _________________________________________
Address ____________________________________________ City _______________________________ State _______ Zip _____________
Address change (check box if applicable) h
HRA/FSA UNREIMBURSED MEDICAL EXPENSES – List each separately
Patient Name
Date of Service
Provider of Service
h HRA
h FSA
Service Description
Reimbursement Amt
1
2
3
4
5
Attach an Explanation of Benefits showing patient name, date of service, and amount paid. If medical expenses are not supported by the
proper documentation (e.g. receipts, EOBs), then by signing below you certify that you have not been reimbursed and will not seek reimbursement
from any other plan of health benefits. Employee Certification: _______________________________ Date : ___________________
TOTAL
FSA DEPENDENT CARE EXPENSES – List each separately
Dependent Name
Date of Service
Provider of Service/ID#
Service Description
Reimbursement Amt
1
2
3
4
5
TOTAL
TRANSPORTATION EXPENSES – List each separately
Service Description
Reimbursement Amt
1
2
3
4
5
TOTAL
Attach an itemized bill and receipt of payment showing dependent name, date of service, provider of service/ID# and amount paid.
I request reimbursement from my Flexible Spending Accounts (FSA) as listed above and certify that these are eligible medical and/or dependent care expenses that my dependents or I have incurred. I certify that
the medical expenses qualify as deductible expenses for federal income tax purposes, meet the requirements of the Plan document and will not be reimbursed by any other source or used as a deduction on my
personal income tax return(s). Further, I certify that the dependent care expenses qualify as valid expenses under the Plan document, that I will not seek reimbursement of the expenses from any other dependent
care plan and that I will not use the expenses for a deduction or credit on my personal income tax return(s). Further, by requesting reimbursement of dependent care expenses, I understand that I must file IRS Form
2441 with my federal income tax return. I hereby authorize the Plan and its service provider (RHS), and their respective agents, employees, sub-contractors, and assigns to use the information provided above to
administer the Plan (including the evaluation of eligibility for reimbursement under the Plan) and to detect or prevent fraud or misrepresentation and to further disclose any and all such information as is reasonably
required for such purpose. I further authorize any provider, insurer, or other entity to release any health or treatment information for the purpose of determining eligibility for Plan benefits or to detect or prevent
fraud. I hereby expressly waive and release any claims related to the use, disclosure, or release of information so long as the information is used in furtherance of administering the Plan (including the processing
or evaluating my claim for benefits under the Plan) or detecting or preventing fraud. This authorization does not and is not intended to in any way limit any right the Plan, RHS, or their respective agents, employees,
sub-contractors, and assigns may have under applicable state or federal law or regulation regarding the use of such information.
Employee Signature: ______________________________________________________________ Date: ______________________
© Redwood Health Services. www.rhs.org. Call 800-548-7677, ext.108 for more information. 2754 1215
Reimbursement Form
Fax completed form to 707-525-4223 or mail to:
Redwood Health Services • 3510 Unocal Place, Suite 108 • Santa Rosa, CA 95403
Patient/Dependent Name
Service
HRA FSADC TE
h
h h h
HRA FSADC TE
h
h h h
HRA FSADC TE
h
h h h
HRA FSADC TE
h
h h h
Date of
Service
Provider of Service/ID#
Service Description
Reimbursement
Amount
6
7
8
9
HRA FSADC TE
h
h h h 10
HRA FSADC TE
h
h h h 11
HRA FSADC TE
h
h h h 12
HRA FSADC TE
h
h h h 13
HRA FSADC TE
h
h h h 14
HRA FSADC TE
h
h h h 15
HRA FSADC TE
h
h h h 16
HRA FSADC TE
h
h h h 17
HRA FSADC TE
h
h h h 18
HRA FSADC TE
h
h h h 19
HRA FSADC TE
h
h h h 20
HRA FSADC TE
h
h h h 21
HRA FSADC TE
h
h h h 22
HRA FSADC TE
h
h h h 23
HRA FSADC TE
h
h h h 24
HRA FSADC TE
h
h h h 25
HRA FSADC TE
h
h h h 26
HRA FSADC TE
h
h h h 27
HRA FSADC TE
h
h h h 28
HRA FSADC TE
h
h h h 29
HRA FSADC TE
h
h h h 30
HRA FSADC TE
h
h h h 31
HRA FSADC TE
h
h h h 32
HRA FSADC TE
h
h h h 33
HRA FSADC TE
h
h h h 34
HRA FSADC TE
h
h h h 35
HRA FSADC TE
h
h h h 36
DC = Dependent Care
TE = Travel Expenses
© Redwood Health Services. www.rhs.org. Call 800-548-7677, ext.108 for more information. TOTAL
2754 1215